Athletics Alternate Year Permit

Office of Catholic Schools - Diocese of Madison

Student Name *

Grade *

Age *

Sex *

Date of birth *

Place (county and state) *

I hereby give my permission for the above named student to compete and represent his/her school in sports. I further agree to be financially responsible for the safe return of all athletic equipment issued to him/her.
I also attest to the fact that the above named student has not been hospitalized or suffered any serious illness or injury since the time of his/her last physical examination. If the above has suffered any of the above or has been hospitalized for any reason since the date of his/her examination - PLEASE DO NOT SIGN THIS CARD. THIS STUDENT MUST BE RE-EXAMINED - another examination card should be obtained from the school.
PARENT: If you are unsure of the seriousness of illness or injury, consult with your family doctor.

Signature of Parent or Guardian *Typing your name in this box indicates your electronic signature.

Email *

Date

ALL BOYS AND GIRLS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE AND/OR PARTICIPATION.